Play Therapy Interventions for the Grieving Child

Play Therapy Interventions for the Grieving Child Order Description (support with peer-reviewed articles) 1.What do you see as the most important considerations in treatment related to childhood traumatic grief? 2.Reflecting on the needs grieving children and their families bring to therapy, research techniques and interventions that you can use in play therapy. 3.highlighting the connection between the presenting problems and the evidence-based interventions that are best suited for these problems. 5 FILIAL PLAY THERAPY FOR GRIEVING PRESCHOOL CHILDREN HILDA R. GLAZER Researchers have come to understand that childhood mourning is a normal process and does not necessarily result in psychopathology and developmental dysfunction (Oltjenbruns, 2001). The experience of loss and exposure to trauma can affect the child's development in either a positive or a negative way. Children are resilient and may not have any adverse reactions or negative behavior changes, or the loss may result in psychological distress and behavioral change. Understanding the impact of loss in a child's life and developing effective interventions is the focus of this chapter. In this chapter, I present filial therapy as an empirically validated intervention for the grieving preschool child. Taking an ecological perspective, I focus on the individual within the environment. Interpersonal relationships, community resources and conditions, and the various systems within which the person functions all affect the way in which he or she copes and problem solves (Collins & Collins, 2005). The child's functioning is then related to the others' reactions and the support available to the child and the family. I begin the chapter with a discussion of developmental issues and play, followed by a discussion of children's grief. Play interventions and filial therapy are presented with supporting research and illustrated by a case study. The chapter ends with suggestions for future directions. 89 http://dx.doi.org/10.1037/12060-005 Play Therapy for Preschool Children, edited by C. E. Schaefer Copyright © 2010 American Psychological Association. All rights reserved. Copyright American Psychological Association. Not for further distribution. CONCEPTUALIZING INTERVENTIONS FOR THE PRESCHOOL CHILD Play is an important part ofthe child's life. All children use play therapeutically as a way of dealing with stress (Elkind, 2007) and processing events in their lives. In a therapeutic playroom, the therapist provides a safe place for the child to play and process life events. The relationship that develops between the child and the therapist is a critical piece of that process. The therapist provides the context in which expression occurs. The communication in the playroom is bidirectional, with both the child and the therapist responding to the interaction. The child has to depend on the adult to see the need for therapy and to make the arrangements. However, when one is working with grieving or traumatized families, it is difficult to separate the adults' experience and response from those of the child. Some adults, in my experience, see the child's response as the same as their own and are unable to differentiate between the two. Helping the adult to differentiate becomes one ofthe goals of therapy. When conceptualizing the interventions for a particular child, there are a number of questions that should be raised. These include the following: • What is the presenting issue? • How does the family system affect the presenting problem? • What are this child's needs? • Who is going to have the greatest impact on the child? • Which intervention will have the greatest potential to facilitate change? Changes in behavior are often the presenting reason. All of a sudden, a child cries easily, is clingy, shows regressive behaviors, or acts out in ways that are new to this child and are disturbing at home and preschool. For the preschool child, the answers to the second and third questions are determined through interaction with the family and child and understanding what brought them to therapy. The answer to the fourth question is often the parent rathet than the thetapist, and one intervention that should be considered in treatment planning with the preschool child is filial therapy. Filial therapy provides the opportunity for the parent to become the child's primary therapist under the guidance of the play therapist. Although still child centered, the intervention uses the attachment bond between parent and child to facilitate change and provide the context for processing. The playroom becomes a place where the parent and child will have something special. 90 HILDA R. GLAZER Copyright American Psychological Association. Not for further distribution. THEORETICAL FOUNDATIONS OF FILIAL THERAPY Filial therapy, or child-parent relationship training, is a theoretically integrative approach combining elements of psychodynamic, humanistic, behavioral, cognitive, social learning, attachment, and family systems theories. However, the primary theoretical basis is client-centered play therapy. Moustakas (1959), in describing relationship therapy, saw therapy as a unique growth expetience created by one person who needs help and another person who accepts the responsibility of offering it. The parallel in filial therapy is that it is based on the parent-child bond and the assumption that the parent has more emotional significance to the child than does the therapist. The parent and child are developmentally linked, and the playroom becomes a place where they learn and grow together. In his experience, Moustakas (1959) found that "parents recognize the significance of their own participation and are eager to explore their relationship with the child, to express their interests and concerns, and to discover new ways of approaching him" (p. 169). My theoretical base—developed while studying under Garry Landreth at the University of North Texas and then in working with Louise Guemey—is client centered with a psychoeducational group therapy model. Relational-cultural therapy is related theoretically to filial therapy in that many of the guiding or core principles are similar. Relational-cultural therapy is based on a set of core principles that include the following: • people grow through and toward relationships throughout the life span • movement toward mutuality rather than movement toward separation characterizes mature functioning • relational differentiation and elaboration characterize growth • in growth-fostering relationships, all people contribute, grow or benefit; development is not a one-way street • therapy relationships are characterized by a special kind of mutuality. (Jordan, 2000, p. 1007) According to Jordan, the work of relational-cultural therapy is understanding the individual patterns of connections and disconnections. In filial therapy, the relationship between the parent and the child becomes the focus, and often the restoration of that relationship is the goal of therapy. For the child experiencing trauma or loss, the parent and child use the playroom to explore the meaning ofthe experience for the child, and both the parent and the child learn and grow in the experience. Filial therapy encourages and reinforces that empathy and mutuality. The construct of mutual empathy suggests that both individuals in a relationship are affected by the othet (Jordan, 2000). This supports the parent's role in filial therapy because the parent-child bond already exists and is strengthened in the process of the therapeutic encounter in the playroom. FILIAL PLAY THERAPY FOR GRIEVING PRESCHOOL CHILDREN 91 Copyright American Psychological Association. Not for further distribution. The model for filial therapy is "a competence-oriented psychoeducational framework" (VanFleet, 1994, p. 2) in which therapists teach parents to conduct special playtimes, work with them on development of skills, and eventually help them to integrate the playtimes and parenting skills at home. Training for filial therapy is provided through a number of training institutes and associations, and courses in filial therapy are provided at universities, often within counseling or counseling psychology departments that offer courses in play therapy. As with all therapeutic interventions, filial therapy should not be conducted without proper training. FILIAL THERAPY MODEL Filial therapy was developed in the 1960s by Bernard and Louise Guemey at Rutgers University and Pennsylvania State University. In her 2000 article, Louise Guerney reviewed the rationales originally developed by Bernard Guemey in 1964: • Child problems are often related to a lack of parenting knowledge and skill. • Playing with their child in a therapeutic role should help parents and children to relate in a more positive and appropriate way. • There is precedent in the use of play sessions in the work of earlier client-centered therapists. • Much of the resistance to therapy on the part of parents is eliminated. • The parent-child relationship is one of the most significant in the child's life; thus, the potential for change is greater with the parent than with a therapist. Originally applied to children with typical behavior and/or emotional problems in lower middle to middle-class White urban and suburban intact families, variations have focused more on the interaction between parent and child. Foley, Higdon, and White (2006) described filial therapy as "relationshipbased therapy model built on the assumption that under certain conditions, a safe and secure context will be created to foster intimacy and understanding between parent and child" (p. 39). The method has now been applied successfully with many ethnic and racial groups (e.g., Lee & Landreth, 2003); lower income families; divorced, blended, foster, and adoptive families (e.g., Bratton & Landreth, 1995; Glazer & Kottman, 1994); children with chronic illness (e.g., Glazer-Waldman, Zimmerman, Landreth, &. Norton, 1992); grieving children (e.g., Glazer, 2006); and parent surrogates in the United States and abroad. The effective- 92 HILDA R. GLAZER Copyright American Psychological Association. Not for further distribution. ness of filial therapy has been demonstrated; parents learn to be more accepting of their children, allow them more self-direction, and are more empathic. Louise Guemey (2000) summed it up in this way: Based on the variations in application of [filial therapy] that have proven workable across a range of populations, we think that [filial therapy] is a remarkably robust approach that can be shorter or longer, used with groups or individual families (with only a single parent as well), applied in inadequately] sized offices or lovely treatment rooms, and still be depended upon for bringing about desired change, (p. 13) Filial therapy is conducted in a consistent, manualized approach using the original long approach of the Guemeys, the Landreth 10-week model, the VanFleet model, or modifications of these models (Carmichael, 2006). DEVELOPMENTAL ISSUES Each age brings with it new opportunities for growth and new challenges. Children use play to nourish their cognitive, emotional, and social development at all ages (Elkind, 2007). The additional challenge for the preschool child is the development of a sense of competition. These children also develop gender roles and become more independent. Cognitively, they are developing more realistic concepts of the world, learning to follow verbal instructions and pay attention. They are both learning and creating symbols (Elkind, 2007). As they enter preschool, they begin to play with others and learn social rules. Elkind (2007) postulated that three elements are necessary to a happy and productive life: love, play, and work. Of these, "Play is the dominant and directing mode of learning during this age period, and children learn best through self-created learning experiences" (Elkind, 2007, p. 7). It is important to note that although traumatic experiences such as the death of a loved one will have an impact on preschoolers' lives, not all young children will develop emotional or behavioral problems or psychiatric disorders (Van Horn & Lieberman, 2004). Summarizing the research on resilience, Van Horn and Lieberman (2004) listed three factors that protect development in childten who have experienced trauma: (a) a relationship with a caring competent adult, which is the most important; (b) a community safe haven; and (c) the child's internal resources, including easy temperament and average or above-average intelligence. The parent's ability to cope with and respond to the child is critical to the child's ability to cope with the loss. In coping with their own grief, adults are not always able to see the child's grief and may not be able to respond his or her needs. FILIAL PLAY THERAPY FOR GRIEVING PRESCHOOL CHILDREN 93 Copyright American Psychological Association. Not for further distribution. Grief-Related Developmental Issues The grief of preschool children must be placed in the context of development. That is, preschool children think about death in a qualitatively different way than do older children. Preschool children do not understand universality of death; they do not see that death is permanent and that death means that all bodily functions cease (Oltjenbruns, 2001). Because the preschool child believes that death is reversible, he or she may ask questions about when the person who died is returning home (Oltjenbruns, 2001) or think that he or she can go visit the person in heaven. This can be distressing to grieving adults. Death for a child is a nonnormative life event. It confronts the child with crisis. The impact on child development may be positive or negative, and there is the potential for psychological harm as well as the opportunity for growth. Often, preschool children do not have the language capacity to describe their feelings or ask for what they need. They are often unable to draw comfort from the words of others (Oltjenbruns, 2001). Grief is expressed through play and through behavior. The behaviors will vary and will represent the way the child copes with the situation; they are the clues to how the child is coping and his or her emotional state (Oltjenbruns, 2001). But it is also important to note that the preschool child may constrain his or her emotional reactions in response to the caretaker's responses (Oltjenbruns, 2001). How the adults are grieving and coping and how they interact with the child will also affect the child's response. Changes in behavior may occur shortly after the death, and others may appear after some time. Their duration may be either short or long term. Some of the behaviors that may appear include the following: • Children may exhibit a fear of being separated from the parent: crying, whimpering, screaming, immobility or aimless motion, trembling, frightened facial expressions, and excessive clinging. • Parents may also notice children returning to behaviors exhibited at earlier ages (regressive behaviors), such as thumb sucking, bedwetting, and fear of darkness. • Children in this age bracket tend to be strongly affected by patents' reactions to the traumatic event. • Childten may use defense mechanisms of denial and proj ection. • Children's explosive emotions may be an outward expression of grief work directed toward anyone available. • Children tend to be fairly protective of themselves and their emotions when they are with other children. • In normal mourning, anger expressed toward one target or another is the rule (Bowlby, 1980). 94 HILDA R. GLAZER Copyright American Psychological Association. Not for further distribution. • Children may experience a wave of overwhelming thoughts. • Children may dream of the person who died. • Children may show not-uncommon dismption in eating and sleeping patterns. • Children may feel a sense of insecurity and abandonment and a wish to be protected from future loss. • Children may feel guilt over being a survivor. • Children may feel guilt over expressing any kind of joy or happiness in life. One phenomenon that typically occurs with preschool children is that they appear to vacillate between experiencing their loss and engaging in normal activities (Oltjenbruns, 2001). This is often disconcerting to adults taking care of the child who do not understand that this is typical behavior. Many children find it important to continue a bond with the deceased person as they deal with and accommodate to the loss (Oltjenbruns, 2001). For example, preschool children may place the deceased person in their drawings, often as an angel-type figure but sometimes as part of the family scene. In reviewing the literature on childhood grief, Oltjenbruns (2001) developed a list of preschool children's psychological reactions that includes emotional distress, separation anxiety, feat that others will also die, death fantasies, learning difficulties (concentration difficulties), and guilt. In understanding the impact ofthe loss on the child, it is important to view it in the context of primary and secondary losses. The primary loss is the person who died—the loss of a personally meaningful relationship and perhaps the loss of a primary attachment figure. The secondary losses include those related to changes in life and routine after the death. If the family moves, there is the loss ofthe house; the child's room; and often the neighborhood, school, and friends. There may be other changes in routine that may be upsetting to the child. One child showed this in her play by taking all of the furniture out of the dollhouse and putting it under the large stuffed animal in the room and then sitting on it. She never said a word to me or her mother about how she felt about moving. She did this a few more times before coming in one day and setting up the dollhouse and putting the family in the car and driving them to the house. PLAY INTERVENTION PROCEDURES Parents and caregivers may bring the child in shortly after the death, or they may wait until the child becomes symptomatic. There is no evidence of an impact of delay on outcomes in young children (Van Horn & Lieberman, 2004). The therapeutic value of enactment through symbolic play is that it allows for reworking and mastery of the traumatic events. For the grieving or FILIAL PLAY THERAPY FOR GRIEVING PRESCHOOL CHILDREN 95 Copyright American Psychological Association. Not for further distribution. traumatized child, the therapeutic environment must create a climate for posttraumatic play (Gil, 1991). The child reenacts the events in an effort to master them (Gil, 1991). Often, the child will set up the same play sequence in multiple sessions with nearly identical actions and an identical outcome. The potential benefit of this play is that although the child is remembering events that are frightening or anxiety producing, he or she is going from a passive to an active stance in controlling the reenactment (Gil, 1991). Gil also suggested that in the controlled, safe environment ofthe playroom, the child is gaining a sense of mastery and empowerment. When selecting interventions, be careful that the intervention does not cause inadvertent harm. Children may not have the coping strategies to withstand these interventions (Shelby, 2007). Using a nondirective approach allows the child rather than the therapist to choose when to address or process the death. Another consideration is the change in the family and family system that results as a natural consequence of filial therapy. The changes that occur in the relationship in the playroom transfer or generalize to life outside the playroom and to the family for both the parent and the child engaged in this special playtime. Toys The toys in the playroom for filial or play therapy include the following groupings: • real-life toys, • acting-out or aggressive toys, • toys for creative expression, • family or nurturing toys, • scary toys, and • pretend and fantasy toys. In the playroom, I have found that younger children use toys within reach and often pick a toy that they have at home. So I make sure that some in each category are at eye level and below. The chalkboard and paper and markers are also favorite activities, as are clay and Play-Doh. Nurturing play is often a theme, with toddlers using the kitchen and clay and paper to make meals. Nurturing play also occurs when the toddlers include me and the parent in their play, such as preparing or giving us dinner. Most of the toddler's play is solitary, however. Some children start the early play sessions by asking me to tell them what each thing they pick up is or what it is for. My response is that in the playroom, they can decide. Often this only continues for two sessions. 96 HILDA R. GLAZER Copyright American Psychological Association. Not for further distribution. Filial Therapy Model I have modified the 10-week model developed by Garry Landreth (1991) to be flexible and meet the needs of the family and child. The rationale for the change is based on time rather than the elimination of any skill or activity. When therapy is done one on one, less time is needed than with a group. There is a consistent sequence of learning and practice, following the outline developed for our original research on filial therapy (Glazer-Waldman et al., 1992). In my practice I use play therapy or filial therapy or a combination, and I use two processes: (a) one in which play therapy is conducted for the first three to five sessions and (b) one in which filial therapy begins right away. One ofthe goals ofthe first session with the parent is to determine the best intervention for the child on the basis of the presenting problem and the child-family history. One of the factors that detetmines which process is used is whether the parent or guardian is willing to be part ofthe process. Another is family dynamics: I look at the relationship between parent and child and note the patent's ability to parent in a loss or trauma situation. Some parents are grieving and unable to participate in filial therapy at the time that I am seeing the family. Others have both the ability and the desire to participate in therapy for their children. Part ofthe discussion includes the importance of play to the child developmentally. I explain the process and appropriateness of filial therapy. If the parent agrees to participate in filial therapy, I set a schedule for meetings with the parent and give parents either a workbook with information, articles, and exercises that I developed ot the handbook for parents developed by Rise VanFleet (2000). Session 1 The goal of the first session is to introduce the parent to the goals of filial therapy and to set goals for the patent and child. Behavioral goals with observable outcomes are set so that the parent can see changes. Typical goals may include • increasing the parent's understanding of his or her child, • helping parents recognize the importance of play in the child's and the parent's life (VanFleet, 1994), • establishing an optimal relationship between parent and child, • improving emotional and behavioral adjustment, • increasing the parent's warmth toward and trust in the child (VanFleet, 1994), and • providing a nonthreatening place where the parent can deal with his or her own issues as they relate to the child and parenting (VanFleet, 1994). FILIAL PLAY THERAPY FOR GRIEVING PRESCHOOL CHILDREN 97 Copyright American Psychological Association. Not for further distribution. Homework for the first week is for the parent to find something new about the child and to list three of the child's strengths. There is also a discussion of the role of play and playing. Session 2 The objective of the second session is to introduce emotional development and practice basic skills. The homework is reviewed. There is a short review of emotional development and the ways in which people communicate their feelings. On the basis ofthe parent's interest level, I may suggest readings. The first two basic skills are reflective listening and tracking. Reflective listening is when the therapist or parent repeats what the child has said in a slightly different way. There can also be reflection of feeling in which the therapist or parent says the feeling that appears to be underlying what the child said. The child might say, "I am getting the frogs out; I can't find the Daddy frog." The parent or therapist might say, "You are looking for the frogs, but you have not found the Daddy frog yet." However, if reflecting the feeling, the response might instead be "You are sad that you cannot find the Daddy frog." This skill is typically introduced to the parent by going over a tape of a play therapy session so that the parent can see the skills, critique the actions, and ask questions about the process. Part ofthe time is spent in the playroom, demonstrating and trying out the skills, with the therapist and the parent taking turns playing the child. Tracking is when the therapist responds to what he or she sees in observing the child's play. In line with the previous example, the child may be lining up the frogs with the two larger frogs in front and the others behind. The response might be "You lined the frogs up with the two big ones in front and the smaller ones behind them." Both of these skills demonstrate to the child that the parent is there and that he or she is hearing them and is interested in their world. The parent's homework for the week is to practice reflective listening and tracking for 5 minutes each (e.g., the parent is challenged to have a 5-minute conversation with another adult without asking any questions). Part of this session and each of the following sessions is for the parents and therapist to talk about family system issues and the parent's concerns. Session 3 The objective ofthe third session is to prepare the parent for the special playtimes with his or her child. The first task is to review the homework and then to practice the skills in the playroom with the therapist playing the child's role. The parent's level of skill in tracking and listening determines the day's objective. Parents are asked to role-play these skills as part of the session. Parents judge their own level of comfort with the skills, and the ther- 98 HILDA R. GLAZER Copyright American Psychological Association. Not for further distribution. apist provides feedback about things that were done correctly and things that might be improved. Handouts with the skills broken down into parts are used to provide guides for skills. If the parent's skill level is inadequate, then the third session is spend in review. If the parent's skill level is adequate, then the next step is to review the basic tenets of client-centered play therapy following the principles set out by Axline (1947). The list of toys for filial therapy is shared, and the site for the play session is discussed. Presenting the sessions to the child is one ofthe major things to review. Presenting the special playtime as truly being a time for parent and child with no interruptions and as a special time for them to be together sends the message that this is an important and unique time for both the parent and the child. One father told me that the time in the car alone together to and from the playroom became important to him and his child and part of the special time that they had together. There is also a discussion of emotional development and naming emotions, leading to a discussion of why we reflect emotions and practice in reflecting emotions. Homework for Week 3 is to buy the toys or collect them in a box, to tell the child about the play sessions, and to practice reflection and tracking. Session 4 This session is the first with the child in the playroom. In my playroom, I can sit in the hall and see all of the room. An agency playroom may have one-way mirrors with the capability to videotape or communicate with the parent while the session is in progress. The parent and child play for 30 minutes with me watching and videotaping if possible. If necessary, I can interject comments and make suggestions to ease the way for the parent. Session 5 The objective of the fifth session is to review the first play session and to review and practice skills as needed. The first question to the parent is, "Did anything seem different this week after the play session?" This usually becomes the basis of an important discussion about the parent-child relationship. At this session, limit setting is introduced because it usually comes up in the first-session review. I have a conversation about communication, using some of the rules for communication between parent and child developed by Haim Ginott (1959). The focus is on the following: 1. If you cannot say it in 10 words or fewer, do not say it. 2. Never ask a question to which you already know the answer. 3. Be an emotional thetmostat, not a thermometer (i.e., a thermostat can be changed, but a thermometer just takes the measure). FILIAL PLAY THERAPY FOR GRIEVING PRESCHOOL CHILDREN 99 Copyright American Psychological Association. Not for further distribution. 4- It is not what you said, but what you say after what you said (e.g., when you yell because you had a bad day, you can come back and tell the child that you did not mean to yell—it was your bad day speaking). The following sessions are play sessions in the playroom with review of tapes shortly thereafter. The parent often quickly notices how some of the skills transfer to the rest of the week and the resulting changes in the family system. The transfer from the play session to the rest of the week often seems to the parents to be an important change. Reviewing the original goals for filial therapy often reveals that other positive changes have occurred in the relationship. Often, parents see their child as a separate individual rather than seeing the child's issues and concerns as a reflection of their own. After there is a comfort level and adequate skill level, the play sessions are moved to the home with the parent videotaping and reviewing the tapes with me. The termination phase of filial therapy begins when the parent and child are conducting the sessions at home, and they begin to see it as part of the weekly routine. During the final session with the parent, I review the goals set at the first session. The value of continuing the play sessions is discussed. There are follow-up phone calls with the option for additional sessions at 3 and 6 weeks after termination. Patents are usually still doing play sessions and report that they have continued to see filial therapy as reinforcing and sttengthening their relationship with their children. Some may have expanded it to their other children and ask how they can use it with older children and teens. The transfer to daily life usually occurs naturally once the parent is comfortable with the skills, and the new way of interacting with the child remains even when the special play sessions end. EMPIRICAL SUPPORT In reviewing the research on childhood bereavement, Oltjenbruns (2001) noted shortcomings and issues that included sample selection, datagathering techniques, not taking into account mediating variables, and weaknesses in the interpretation of data. Anothet teview article by Johnson, Kent, and Leather (2005) concluded that interventions used to strengthen the bond between parent and child are effective and have been used effectively to reduce distress and behavioral difficulties. Guo (2005) reviewed studies on filial therapy, focusing on those using the 10-week model across a variety of cultures, and concluded that filial therapy held promise for therapists in China and throughout the world. 100 HILDA R. GLAZER Copyright American Psychological Association. Not for further distribution. Van Horn and Lieberman (2004) reported that there is research supporting successful treatment of children who have experienced trauma with group and individual interventions. One model that worked was the mother-child group; however, the authors noted that the mother had to be able to recognize the effects of the trauma on the child. In reporting on their earlier research, Van Horn and Lieberman (2004) described the process as one that was specifically developed for children who had witnessed domestic violence. Specific goals of this therapy included normalizing the experience, placing the experience in perspective, and restoring the reciprocity in the relationship between parent and child. Although a relatively new therapy, filial therapy has been heavily researched since its inception and has been adapted and applied in a variety of settings and with a variety of populations, resulting in a rich quantitative, evidence-based, and qualitative research base supporting its effectiveness. Guemey (2000) noted that between 1971 and 2000, a large number of studies with a variety of populations of children and parents supported filial therapy. The studies by Guemey and others in the 1970s using the original protocol fot filial therapy also used the same measures originally developed by Guemey, thus giving the advantage of comparison with those studies and adding suppott for the effectiveness ofthe protocol for decreasing negative behaviors such as aggression (Guemey, 2000). Rennie and Landreth (2000) reviewed a number of studies of filial therapy and concluded that filial therapy did promote and enhance the parent-child relationship. Parents could learn the clientcentered play thetapy skills necessary to become effective therapeutic agents with their children. They found that research supported filial therapy as an effective intervention for increasing parental acceptance, self-esteem, and empathy; making positive changes in the family system; increasing child selfesteem; and decreasing parental stress and child behavior problems. Additionally, Landreth's (1991) 10-week variation has been extensively studied at the University of North Texas and found to be an effective intervention with different populations. In their meta-analysis of play and filial therapy research, Bratton, Ray, Rhine, and Jones (2005) concluded that their research strongly supported the adoption of filial therapy as an effective therapeutic modality in working with children. A recent qualitative study by Foley et al. (2006) found that the parents who participated in filial therapy attributed positive and progressive meaning to their experience. These parents also reported that they increased their selfawareness, problem-solving resources, and confidence and improved their relationships with theit children. The model's robustness is seen in the research on its application to various settings and populations. For example, research has been published on ethnic and racial groups (e.g., Guo, 2005; Lee & Landreth, FILIAL PLAY THERAPY FOR GRIEVING PRESCHOOL CHILDREN 101 Copyright American Psychological Association. Not for further distribution. 2003); lower income, divorced, blended, foster, and adoptive families (e.g., Bratton & Landreth, 1995; Glazer & Kottman, 1994); children with chronic illness (e.g., Glazer-Waldman et al., 1992); and grieving children (e.g., Glazer, 2006). The age of children in most of the filial studies reported was 4 to 10 years. Bratton et al. (2005) found a mean of 7 in their meta-analysis. I did not find any research on filial therapy with infants and toddlers. Although there is strong empirical support for filial therapy, more research is needed to solidify it as an evidence-based therapy. Longitudinal research is also needed to determine how long the parents should continue the play sessions and filial therapy's long-term effects on the family. CASE ILLUSTRATION A 4-year-old was referred to me because of her 3-year-old sister's death after a short illness. This was traumatic for this family because the illness came on quickly but diagnosis was difficult, and they watched the child decline while it seemed that nothing could be done. Complicating this for the other children in the family is that they lived in a community where another child had died in a similar fashion 2 years before, and the client had played with this child. The client was having nightmares, got angry at others easily, and cried easily. She was clingy with her parents and refused to spend the night at her aunts' or grandparents', which was something that she used to enjoy. The family had a lot of social support, and the mother and father were also seeing a counselor. The mother stated that she wanted to be sure that her children processed this successfully. I brought up filial therapy as a type of intervention to consider, and the mother said she would think about it. To begin to assess where the child was at the present time, I asked the child to draw trees for me—the three-tree exercise. First, the child is told to draw a tree. This child's tree was straight with a long trunk and branches and leaves at the top. The tree was completely colored in, and grass was drawn at the bottom. On a second sheet of paper, the child is told to draw another tree—a tree in a storm. This child drew the same tree with gray clouds and rain and lightning. Rain was on the tree. To me, it looked like the tree was crying. When I asked her to tell me about the tree, she said that the tree was sad because it was raining hard and there was thunder. Next, on a third sheet of paper, the child is asked to draw a third three— the tree after the storm. This tree was laid out horizontally with no leaves or green. When I asked her to tell me about the tree, she said it was dead, and that was all. 102 HILDA R. GLAZER Copyright American Psychological Association. Not for further distribution. My impression was that this was a sad child. She did not clearly see past the trauma at this time. The goal then became to process the grief with the child and help her begin to see past the death to a life that was okay.1 At first, her play was exploratory, and she did not talk to me or make eye contact in the first three sessions. In the fourth session, she drew a picture of her sister and told me that this was her sister in the hospital and that she was now in heaven. She took the picture home with her. Mom called later in the week and told me that she had begun to talk about her sister for the first time since the funeral. After the second session, the mother talked to me about filial therapy, and I gave her a few articles to read. She called and asked to begin filial therapy. Starting at Week 3,1 began filial therapy training with the mother. We met separately during the week for the filial therapy training. At the sixth session with the child, the mother sat behind me while I conducted the play session. At the seventh session, the mother sat in the front and conducted her first play session with my coaching. The next week, the girl did a sand tray in which she placed animal families with parents and children and said that her family had one person in heaven. It appeared that she was working on the changes in her family. She also drew a picture of her family with an angel-like figure that she told me was her sister in heaven. Her mother reported that she was asking where her sistet was and if she could go visit her. The mother told her that no, she could not visit her sister in heaven and that her sister could not visit her. The sixth session matked a significant change. With her mother in the room, the child used the dollhouse and baby dolls to create a scene that was like a typical family dinner before her sister died. Then one of the dolls got sick, and we heard a running dialogue ofthe process the child was going through. She was sure the doll was going to die. The mother processed this with the child. At one point, the child sat on her mother's lap and said, "Why did she have to go ?" Holding her daughter, the mother said that she did not know the answer. In our session later in the week, the mother related how this concern about illness and death came up again because the girl's father had a cold so she was able to reinforce what she had said in session. The mother held five more sessions at home, and we talked after each one. Together, mother and daughter began to process their grief and were able to support each other in it. 'Since the time of this case, I worked with a child who was a year older who drew the three trees and told me that the trees were his dad before, during, and after an illness. FILIAL PLAY THERAPY FOR GRIEVING PRESCHOOL CHILDREN 103 Copyright American Psychological Association. Not for further distribution. CONCLUSION AND FUTURE DIRECTIONS Processing grief together through filial therapy strengthens the parentchild bond and enhances the relationship. Following a death in the family, the parent may not be able to be part of this process, in which case play therapy is a viable intervention. Research has supported the value of including the patent in the process. Filial therapy's potential with a variety of family and child issues is unlimited. Particularly in situations of trauma, loss, and grief, in which the impact is on the family system, filial therapy can be effective in facilitating the family's healing as they process the events together. In supporting the healing process, filial therapy becomes a set of skills that often continue to have a positive impact on the parent-child relationship. The relationship has been changed through play. The child-centered approach provides the context for using filial therapy with preschool children. The therapist meets the child where he or she is and works with the parent to develop the skills necessary to provide the context in which change can occur and in which the relationship between parent and child can be healed or enhanced. Processing grief can become a positive experience for the parent and child, allowing each to see where the other is at this time. It can also help the parent to differentiate between his ot her grief and that of the child. REFERENCES Axline, V. (1947). Play therapy. Cambridge, MA: Riverside. Bowlby, J. (1969). Attachment and loss: Vol. 1. Attachment. New York: Basic Books. Bratton, S., & Landreth, G. (1995). 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